Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa.

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Self-collected versus health-care professional taken swab for identification of vaginal-rectal colonisation with group B streptococcus in late pregnancy: a systematic review.

BACKGROUND: Testing for group B streptococcus (GBS) requires a vaginal-rectal swab in late pregnancy. OBJECTIVE: A systematic review of the test accuracy of a self-collected swab compared with a health-care professional collected swab in the diagnosis of GBS colonisation. SEARCH STRATEGY: The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects [DARE] and the Cochrane Central Register of Controlled Trials [CENTRAL]), EMBASE, MEDLINE and Trip were searched in May 2022. SELECTION CRITERIA: Randomised trials, test accuracy studies or diagnostic yield studies that compared the accuracy of a self-collected vaginal-rectal swab, compared to that taken by a health-care professional, for the detection of GBS colonisation in the third trimester. DATA COLLECTION AND ANALYSIS: Two researchers independently screened, selected studies, extracted data and assessed study quality. MAIN RESULTS: 10 studies, with 2578 women were included. Pooled sensitivity of self-collected swabs was 0.90 (95% confidence interval [CI] 0.81 to 0.95) and pooled specificity was 0.98 (95% CI 0.96 to 0.99). CONCLUSION: This study provides reassuring evidence that self-collected swabs for maternal GBS colonisation are highly accurate relative to swabs collected by health-care professionals. Women requiring a swab for GBS colonisation can self-swab with appropriate instructions if they choose. FUNDING: Personal fellowship from the University of Nottingham for KFW.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review.

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.

Intravenous Ceftriaxone Versus Multiple Dosing Regimes of Intravenous Anti-Staphylococcal Antibiotics for Methicillin-Susceptible Staphylococcus aureus (MSSA): A Systematic Review.

BACKGROUND: Methicillin-susceptible Staphylococcus aureus (MSSA) is a common pathogen associated with a range of clinically important infections. MSSA can cause deep-seated infections requiring prolonged courses of intravenous antibiotic therapy to achieve effective resolution. The move toward ambulatory or outpatient delivery of parenteral antibiotics has led to an increase in the use of ceftriaxone as a pragmatic first choice given its advantageous single daily dosing schedule. OBJECTIVE: To compare the efficacy of once daily ceftriaxone in the treatment of infections due to confirmed or suspected MSSA to multiple dosing regimes of anti-staphylococcal antibiotics. METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Global Health, PubMed, EMBASE and CINAHL for randomised controlled trials as well as prospective and retrospective cohort studies that compared ceftriaxone to any multiple dosing regime of anti-staphylococcal antibiotics. Outcome measures were the proportion of patients with a resolution of infection based on time after initiation of therapy, adverse reactions, recurrence and duration of hospital admission. RESULTS: We included two randomized controlled trials, one prospective observational study and three retrospective cohort studies (643 participants; 246 children, 397 adults). There was no difference in time to resolution of symptoms. The number of adverse reactions, recurrence of bacteraemia and duration of hospital stay were not significantly different between ceftriaxone and other anti-staphylococcal antibiotics. CONCLUSIONS: Based on a small number of low-quality studies, ceftriaxone is as effective as multiple dosing regimes for the treatment of infections due MSSA. An appropriately powered randomized trial is required to demonstrate equivalence and cost effectiveness.

Early warning systems in obstetrics: A systematic literature review.

INTRODUCTION: Several versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes. METHODS: We systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous. RESULTS: A total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity-89% (72% to 97%) and specificity-85% (67% to 98%) but low median (inter-quartile range) positive predictive values-41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity. CONCLUSION: Obstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings.

Telephone follow-up after day case tension-free vaginal tape insertion.

INTRODUCTION AND HYPOTHESIS: Post-operative review allows assessment of individual patient outcome, evaluation of any ongoing symptoms and an audit of departmental surgical outcome and therefore represents best clinical practice. Current TVT surgery follow-up practice varies widely, with most centres routinely seeing patients face to face in an outpatient setting. However, unnecessary outpatient attendance can be inefficient and inconvenient for patients and staff. One proposed alternative is telemedical follow-up, as introduced by our unit in 2010. We report on 5 years of experience with telephone follow-up. METHODS: The British Society of Urogynaecology (BSUG) database was searched for all cases of primary retropubic TVT slings performed by the unit in the period 1 January 2010 to 31 December 2014. Cases identified from the BSUG database then had their case notes reviewed. Patients having additional surgery were excluded from analysis. This yielded a cohort of 356 patients. No ethical approval was required for this investigation as it was a simple observational study (clinical audit). RESULTS: Two hundred and sixty-two patients were initially followed up via telephone; the remaining 94 were seen in a conventional outpatient clinic setting. Of the 262 followed up by telephone, 28 patients (10 %) subsequently required review in an outpatient clinic for a variety of reasons. CONCLUSIONS: Telephone follow-up is an appropriate mode of follow-up for uncomplicated primary incontinence surgery. By using telemedicine, 234 patients who would previously have been seen in clinic were followed up remotely, saving valuable clinic time for patients with greater clinical need.

Vaginal Birth After Caesarean Section in Low Resource Settings: The Clinical and Ethical Dilemma.

Vaginal birth after Caesarean section (VBAC) has long been practised in low resource settings using unconventional methods. This not only poses danger to the woman and her baby, but could also have serious legal and ethical implications. The adoption of this practice has been informed by observational studies with many deficiencies; this is so despite other studies from settings in which the standard of care is much better that show that elective repeat Caesarean section (ERCS) may actually be safer than VBAC. This raises questions about whether we should insist on a dangerous practice when there are safer alternatives. We highlight some of the challenges faced in making this decision, and discuss why the fear of ERCS may not be justified after all in low resource settings. Since a reduction in rates of Caesarean section may not be applicable in these regions, because their rates are already low, the emphasis should instead be on adequate birth spacing and safer primary operative delivery.

L'accouchement vaginal après césarienne (AVAC) est pratiqué depuis longtemps au moyen de méthodes non conventionnelles au sein de pays ne disposant que de faibles ressources. Cela entraîne non seulement des risques pour la femme et son enfant, mais peut également donner lieu à de graves conséquences sur les plans juridique et éthique. L'adoption de cette pratique est soutenue par des études observationnelles comptant de nombreuses carences. Cette pratique perdure malgré la publication d'autres études (issues de milieux au sein desquels les normes de diligence sont beaucoup plus élevées) qui indiquent que la tenue d'une césarienne itérative planifiée (CIP) pourrait en fait être plus sûre que l'AVAC, ce qui soulève des questions quant à la nécessité d'insister sur la mise en œuvre d'une pratique dangereuse, compte tenu de l'existence de solutions de rechange plus sûres. Nous soulignons certains des défis à relever pour la prise d'une décision dans de telles situations et traitons des raisons pour lesquelles les craintes quant à la tenue d'une CIP pourraient ne pas être justifiées après tout au sein des milieux ne disposant que de faibles ressources. Puisqu'une réduction des taux de césarienne pourrait ne pas être possible dans ces régions (car ces taux y sont déjà faibles), l'accent devrait plutôt être placé sur l'espacement adéquat des grossesses et sur la tenue d'un accouchement opératoire plus sûr dans le cadre de la première grossesse.